Orthogeriatric co-management care models: The need for integrated practice units

Zhang and colleagues¹ should be lauded for their implementation of an orthogeriatric co-management care model for older adult hip fracture patients, resulting in decreased time to surgery, improved clinical management, and reduced one-year mortality. While these findings explore integrated care delivery models and corroborate previous evidence, we write to call attention to the need to expand these patient touchpoints longitudinally through integrated practice units (IPUs).

IPUs, such as UT Health Austin's Musculoskeletal Institute in the United States and Beijing Tian Tan Hospital's Stroke Unit in China, are practices that organize care delivery through multidisciplinary teams consisting of surgeons, nurses, case managers, technicians, dieticians, psychologists, and others. As in Zhang and colleagues’ approach, these teams conduct pre- and post-operative assessments to create customized care plans that include comorbidity treatment, rehabilitation, and physiotherapy.

Notably absent from their approach, however, is longitudinal patient engagement beyond the orthogeriatric ward. Given that geriatric hip fracture patients experience exceptionally high one-year postoperative mortality rates of up to 30%,² are generally medically complex patients, and require advanced discharge planning and postoperative rehabilitation to regain prior functional status, close longitudinal follow-up is critical.

Zhang and colleagues collect follow-up data at three timepoints post-discharge, but robust, continuous monitoring by care coordinators of patient-reported outcomes and clinical data is integral to well-functioning IPUs. Furthermore, complex patients may require additional post-operative services, such as weight management support, alcohol and smoking cessation programs, and mental health counseling to address psychosocial drivers of musculoskeletal illness.³ IPUs can deliver these services through trained social workers, involving other members of the care team as needed if desired outcomes are not achieved. Finally, longitudinal IPU engagement ensures that patients are seamlessly transitioned back to their primary care environment following recovery and that recommendations for condition maintenance are shared with their primary care providers.⁴

Given that the authors suggest geriatric medicine is under-developed in China¹ and likely in many other parts of the world, effective orthogeriatric IPUs may drastically improve patient outcomes and reduce costs compared to fragmented care by optimizing resource deployment and better engaging patients post-operatively⁵; insights into these systems of care may have benefits for patients beyond countries like the US and China. Healthcare providers are at a crossroads in which they have an opportunity to re-shape the delivery of geriatric care. Doing so, however, will require a critical assessment of integrated models to measure cost-efficacy and outcomes across a broad array of patient-centered metrics. As Zhang and colleagues call for the “scale-up of the orthogeriatric co-management care model,”¹ we encourage the inclusion of IPU-based orthogeriatric care in subsequent prospective trials.

Contributions

All authors contributed to the conceptualization of the manuscript. BJ and SSB drafted the initial manuscript. TA, ECD, and SP provided revision and critique of the manuscript.

Funding

None.

Declaration of interests

The authors have no relevant conflict of interest to disclose.